Advanced Periodontal Flaps
Sonia Leziy Canada
Gingival recession is a serious problem that has been treated with a variety of techniques. Coronally positioned flap, lateral sliding flap, and free gingival graft are used with limited success and unpredictable results.(1-3) The use of the connective tissue graft offers a combination of pedicle flap and free gingival graft. This gives it more versatility. The graft is also more successful because the recipient site provides double blood supply to the graft.
Materials and methods
The exposed tooth is thoroughly root planed and convexities, if present, are eliminated. Some operators treat the surface with a 30-second burnishing of tetracycline or citric acid, and some do not, without resulting in any significant change in the outcome. A split thickness flap is created around the defect. In the original article (4), it was recommended to cut two vertical releasing incisions placed away mesiodistally from the edges of the gingival recession. The coronal margin of the flap is started with a sulcular incision. The interproximal papillae are left intact. The flap extends past the mucogingival line to allow adequate mobilization. Care must be taken not to perforate the flap to preserve the blood supply. Recently, it has been shown that success and esthetics are even greater if no releasing incisions are cut.(5) With this technique a “tunnel” flap is created. The connective tissue graft is introduced under the flap using a couple of guide sutures. The sutures are entered under the flap at its edges and come out at its center. There they are passed through the edges of the graft and slid back under the flap to its edges. By gently pulling on both sutures, the graft is positioned under the flap and tied there. This modification eases the placement of a graft; for multiple adjacent sites, that can sometime be problematic.
Another modification exists when dealing with recession on two adjacent teeth.(6) The tunnel technique is combined with double lateral pedicle flaps to result in better coverage of the graft. Two horizontal incisions are created at the level of the cementoenamel junction and extended distal to the affected teeth, two thirds of the way to the adjacent teeth. At each end, vertical incisions are cut past the mucogingival line to free the flap. Sulcular incisions are made, stopping at the interproximal papilla. The split thickness lateral flaps are elevated by sharp dissection. The midline papilla is next elevated by sharp dissection, to create a tunnel. The graft is placed under the tunnel, sutured in place, and the lateral flaps rotated mesially and sutured to the midline papilla. The technique allows double layer coverage of the denuded areas.
The graft was harvested from the palate by cutting two parallel incisions, 1.5 to 2 mm apart, at a slant into the palate and removing a slice of tissue. The slice was composed of a band of epithelium at its top and a deep band of connective tissue as its main component. Suturing the parallel edges together closed the palate. The advantages of this technique were its ease, the minimal palatal defect created, and the increased comfort to the patient. The rough and ridged surface of our feline and canine patients still prevented us from using this technique.
The next step in the evolution of the technique was to cut an L shaped or a three-sided window into the palate and to remove a split thickness graft from the surface of the palate. The advantage was a graft totally composed of connective tissue. The disadvantage was a larger surgical site requiring hemostasis and suturing. The latest improvement has been to harvest the connective tissue flap through a single incision.(7)
The details of this technique are as follows: the donor area of the palate is anesthetized by block anesthesia of the major palatine and nasopalatine nerves. The blocks are achieved using a local anesthetic containing epinephrine. The first incision is made parallel to the midline, medial to the major palatine groove. The blade is oriented at 90º to the palate. The length of the incision is commensurate with the length of the graft required. For the next incision, the blade is angled at 135º to the palate and an undermining preparation is started within the first incision. With each further stroke of the blade, the angle is further opened until the blade is parallel to the surface of the palate. The sharp dissection of the partial thickness graft is extended until the desired size is reached. The 1.5 to 2.5 mm thick connective tissue graft is separated from the donor bed by cutting to the periosteum on the mesial, distal and medial sides of the graft. The graft can then be detached from the surface of the palate using a periosteal elevator. No releasing incisions are cut into the palate. The harvested tissue is kept moist inside a gauze soaked in saline until it is transferred to the recipient site. A collagen material is placed into the void left by the graft to help clotting and to preserve the palatal contour after healing. The incision is closed using absorbable 5-0 sutures and a layer of tissue glue is added on top of the incision to protect it further.
The graft is trimmed as necessary and placed under the gingival flap and over the defect. It is sutured interproximally to the underlying connective tissue, using 5-0 absorbable sutures. It is recommended to use a P3 reverse cutting needle to minimize tissue trauma. The partial thickness flap is positioned coronally over the graft to cover as much of it as possible without creating tension. It is not imperative that the whole graft be covered. The patient is sent home with the appropriate analgesics and recommendations to feed only soft food for the next seven days and to come for a recheck visit the following week. The graft may appear swollen during the healing phase but this usually subsides with time.
This technique uses both a connective tissue graft and a pedicle flap. The graft is sandwiched between the periosteum and the flap and gets a double blood supply. The increased blood supply is enough to revascularize the entire flap even though only half to two-thirds are covered by the flap. The connective tissue ensures good thickness and keratinization, and diminishes the chance of recurrence of recession. The donor site creates minimal discomfort and heals by primary intention. There is no exposed window of connective tissue that needs to epithelize, requiring care and supervision post-operatively. The technique for this procedure may be more exacting, but it offers more versatility and better results.
1. Bernimoulin JP, Luscher B, and Muhlemann HR. Coronally repositioned periodontal flap. J Clin Periodontol 1968; 39: 65.
2. Grupe HJ, and Warren R. Repair of gingival defects by a sliding flap operation. J Periodontol 1956; 27: 92.
3. Sullivan H, and Atkins J. Free autogenous gingival grafts. III. Utilization of grafts in the treatment of gingival recession. Periodontics 1968; 6: 152.
4. Langer B, and Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985: 715.
5. Zabalegui I et al. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: A clinical report. Inter J Periodontics and Resto dent 1999; 19: 199.
6. Blanes RJ, and Allen EP. The bilateral pedicle flap-tunnel technique: A new approach to cover connective tissue graft. Inter J Periodontics and Resto Dent 1999; 19: 471.
7. Hurzeler MB, and Weng D. A single-incision technique to harvest subepithelial connective tissue grafts from the palate. Inter J Periodontics and Resto Dent 1999; 19: 279.
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